3
Psychotherapy theories are explanations of human functioning and the process of change. As the previous chapters have unmistakably illustrated, the wide array of psychotherapy theories has created vociferous debates about the advantages and disadvantages of particular theories. However, such debates have obscured the importance of theory—any theory—in the process and outcome of psychotherapy. To understand the role of theory in therapy, it is important to keep in mind Jerome Frank’s (Frank & Frank, 1991) common factors in therapy: (a) an emotionally charged and confiding relationship between the healer and the client, (b) a healer who is given special status and is perceived to have the powers to heal, (c) a powerful and cogent rationale for the healer’s actions, and (d) a set of treatment actions that are consistent with the rationale. These components are vacuous without theory; simply, there is no therapy without theory. Every client wants an explanation for what ails that client and a set of therapeutic actions that the client believes will improve his or her condition. The last two components—the rationale and the treatment—emanate necessarily from theory. The therapist needs to have a deep understanding of theory and be able to communicate it convincingly to the client.
In this chapter, several aspects of psychotherapy theories are discussed. First, the nature of theories in psychotherapy is explained to answer the question, What are psychotherapy theories? Next, the importance of theory for the therapist and for the client is discussed. Then, philosophical issues are presented that reveal insights into the arguments about what are “preferred” theories.
It is clear at this point that there are many psychotherapy theories, that they were spawned from different philosophies of science, and that they differ in many important ways. Despite this divergence, there are structural similarities given that the theories address similar questions, albeit with different answers. In this section, the major questions that most theories answer are described. It may be the case that various theories do not address these questions explicitly, but dig a bit below the surface and it will be clear that the theories have the root of these questions at their core.
The first question that each theory addresses is, What is the core motivation of human existence? For example: Are humans motivated to action by instinctual and biological drives? Or: Is the motivation interpersonal and relational in nature? Will people always tend toward “good or evil”? Are we “blank slates” on which life’s lessons are written? Do we respond primarily to the environment (determinism) or can we make conscious decisions on our own (free will)?
Many of these types of questions can be boiled down to two fundamental ones: What are the characteristics of a healthy personality? And how does psychopathology develop? In one respect, these questions are innately developmental: What happens to the human organism that derails healthy development? This question raises the further issue of nurture versus nature. From the nurture perspective, one can ask about critical developmental stages and events that occur to thwart normal development. From the nature perspective, one is interested in the environmental events that lead to an expression of the gene that results in manifestation of pathology.
To a greater or lesser extent, all theories are interested in the role social relations play in the healthy personality and in dysfunction. Some theories place more emphasis on early social attachments, mainly with parents, whereas others examine current social support and social relations. A related question concerns whether problems exist within the individual or are created in the social milieu (e.g., by a dysfunctional family, school bullying, or relational trauma).
An additional set of differences occurs as theories place emphasis on various systems to the exclusion of others. Thus, various theories emphasize affect, cognition, or behavior. It might be said that theories are not so much different from each other, but, rather, it is a matter of relative emphases on particular systems. Other theories may eschew a focus on organismic systems and focus instead on social systems; these theories, for example, would address how culture influences human functioning, particularly psychological well-being and dysfunction.
Needless to say, there are a myriad of questions that theories address and many ways to think about the similarities and differences among theories. One scheme, based on Murdock (2016), for examining these issues is presented in Table 3.1, in which the four major forces of psychotherapy discussed previously are presented along with six particular issues: (a) the philosophy of science from which the theories emanate, (b) the perspective taken on human motivation, (c) the perspective taken on human development, (d) the definition of psychological health, (e) the therapeutic stance and roles of the therapist and the client, and (f) the manner in which the goals and outcomes of therapy are framed. This table provides a schema that will help in understanding the various theories as they are presented in the books that follow.
Table 3.1
Theory |
Philosophy of science |
Human motivation |
Human development |
Psychological health |
Therapeutic stance |
Goals/outcomes |
|---|---|---|---|---|---|---|
Psychoanalytic/psychodynamic |
Positivist/realist |
Pessimistic to neutral; must overcome instinctual urges and early life experiences |
Psychosexual stages of development; early attachment experiences critical |
Healthy defenses, sufficient ego strength, secure attachment style |
Formal, therapist–client roles |
Personality change, resolution of unconscious conflicts, insight, integration |
Cognitive behavior |
Positivist/postpositivist |
Neutral; humans adapt to environment |
Learning paramount, shaped by experience |
Adaptive behavior, adaptive cognitions, absence of dysfunction |
Teacher/consultant |
Distress reduction, symptom reduction, adaptive functioning |
Humanistic–existential |
Phenomenological |
Some optimistic (tendency to self-actualize); some negative to neutral (existential search for meaning) |
Not explicit |
Authenticity, congruence, awareness, acceptance of self and others |
Authentic and present in the here-and-now |
Authenticity, freedom, understanding, meaningful existence, self-actualization |
Multicultural/feminist/narrative |
Postmodern |
Ambiguous; search for meaning; exertion of power |
Context (culture, gender, power critical) |
Empowered, meaningful life; unconstrained by power and isms (e.g., racism) |
Egalitarian, collaborative |
Empowerment; reduction of barriers, oppression, and privilege; opportunity to achieve life goals |
For the therapist, the theory becomes the map for psychotherapy. A map is only a pictorial presentation of the geographic/political/economic space with various delineated routes from one location to another. There are many maps to choose from: road maps, satellite views, topographical maps, climate maps, political maps, economic maps, and so forth. None of these maps is “reality,” but each represents phenomena in a useful way. Some are more useful for some purposes (e.g., driving) than others (e.g., hiking). Psychotherapy theory provides a map for the therapist—not a complete reflection of reality but a useful representation. Each psychotherapy theory gives the therapist a lay of the land and help in getting from point A to point B. In psychotherapy language, the theory provides the basis for case conceptualization and treatment planning. Case conceptualization describes the nature of the psychological problem and dysfunction within the theoretical framework chosen by the therapist. Treatment planning involves how the therapist plans to work with the client to remediate the client’s difficulties. In a way, conceptualization and treatment planning involve explanation and action, two critical components of psychotherapy (Frank & Frank, 1991; Wampold, 2007).
The theory provides the structure for case conceptualization, but the data are provided by the client either directly (e.g., in the clinical interview) or indirectly (e.g., material in the client’s chart or information from assessment procedures; P. S. Berman, 2015; Eells, 2015). Some therapists rely solely on the clinical interview for data and others administer various assessment instruments. Even the choice of assessment instruments reflects theory, as a cognitive behavior therapy therapist might use a symptom-focused measure, whereas the dynamic therapist might use a projective test. Regardless, these data are filtered through the theoretical lens; data without inference have no meaning to the therapist. Of course, any explanation of the client’s problem should be considered tentative, and the therapist should be open to disconfirming his or her conclusions. Disconfirming evidence does not need to result in an abandonment of the theory, but, rather, in a reformulation within the theory. In a sense, using the map metaphor, the map has to be revised as the journey progresses. Of course, the skilled therapist also integrates the best research evidence about the client’s disorder or problems, and the treatment of this disorder or problem, as well as the client’s characteristics, context, and preferences (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006).
Given the variety of psychotherapy theories, which should the therapist choose? This choice is influenced by a variety of intersecting forces but is guided by an overarching consideration: What theory will best help this particular client? The answer to this question is interminable—simply said, it is impossible to say with certainty which theory would benefit the client the most. Yet, there are many essential considerations when choosing a theory as a lifelong pursuit and for a particular client.
Most important, the therapist and the theory must be compatible. Therapists are attracted to therapies that they find comfortable, interesting, and, attractive. Comfort most likely derives from the similarity of the worldview of the theory and the therapist’s attitudes and values. A perusal of Table 3.1 reveals a broad range of basic values, say, in terms of psychological health. Comfort, however, also is derived from the interpersonal demands inherent in the therapy. For example, some theories depend on the presence of the therapist in the here and now more than others; some therapists, because of their interpersonal skills and personality, are more comfortable with intense emotional encounters inherent in such therapies. Other therapists may be more comfortable with the teacher/consultant role of behavioral treatments (see Table 3.1). Interest in the therapy also may come from the intellectual aspects of the therapy; reading psychodynamic theories is a much different experience than reading behavioral theories. Some theories are more reductionistic and pragmatic, whereas others are more philosophical and abstract; a theory that is attractive to one person will turn off another. This is not, most likely, a scholarly calculus in which one catalogs what is attractive about the various theories but, rather, is a visceral reaction. As you read theories in this series, you will find yourself nodding approval and enthusiasm for some, whereas others might bore you—or even anger you. Interestingly, good theories make good reading: In three surveys about “great books” in psychology, Norcross and Tomcho (1994) found many of the top-rated authors were psychotherapy theorists, namely, Sigmund Freud, Carl Rogers, Erik Erikson.
A second consideration, not unrelated to the first, is that the therapist must believe that the theory, as implemented by the therapist, will be effective. A few subtleties here are worth pondering. As discussed previously, some consider evidence-based treatments (EBTs) or empirically supported treatments (ESTs) more effective than other treatments, whereas others might say that although it perhaps has not been proven that EBTs and ESTs are more effective, they clearly are preferred because evidence exists that they are effective. But, as discussed in Chapter 4, such claims ignore an important aspect related to the delivery of psychotherapy—namely, the therapist! In the clinical trials that produce the evidence, the ESTs or EBTs typically are delivered by therapists who have an allegiance to the treatment. These trials do not have much to say about the effectiveness of ESTs or EBTs delivered by those who do not find them appealing. Indeed, there is research that shows that the allegiance to the treatment is related to outcome (see Chapters 4 and 5). There also is conclusive evidence that much of the variability in outcomes is due to the therapist (Baldwin & Imel, 2013; Castonguay & Hill, 2017; Kim, Wampold, & Bolt, 2006; Saxon & Barkham, 2012; Wampold, 2006; Wampold & Brown, 2005). Therefore, it makes little sense to discuss the effectiveness of a particular treatment without considering who is giving the treatment. Thus, the question, Which treatment will be most effective? is incomplete. The better question is, Which treatment delivered by me will be most effective? The answer to the better question is much more complex but has much to do with attraction to the therapy. Therapists providing a treatment that they find interesting and compatible likely will be more effective than therapists delivering a treatment not to their liking.
A further subtlety is centered on the idea of belief in a treatment. One interpretation of this term is that it connotes a conviction that the theory is a true explanation of the client’s dysfunction. According to this interpretation, belief is derived from the “truthiness”1 of the theory; some theories are more valid explanations for psychological dysfunction and its remediation than others. Such claims are philosophically and empirically problematic; simply, as is discussed in this chapter and the next two chapters, no theory is clearly more truthful than another (see Wampold, Imel, Bhati, & Johnson-Jennings, 2006, for a discussion of this issue). This raises a thorny issue: How does one have belief in a theory if the “truthiness” of the theory cannot be established, philosophically or empirically? Ironically, the resolution is subtlety simple: The belief that the therapist must have is that the treatment, as delivered by the therapist, will be effective. This is different from the belief that the treatment is the most effective, most truthful, most useful, most efficient, or best in any other way.
A third consideration when choosing a theory is related to mastery. To be effective, a therapist practices and continually improves, learning initially from master therapists. In many ways, one learns psychotherapy at the foot of a master (Orlinsky & Rønnestad, 2005). Therapists in training have limited opportunities to learn various therapies and therefore are restricted to learning theories for which there are expert instructors and supervisors. It is awfully difficult, if not impossible, to learn a theory on one’s own. And, as is discussed in the next section, it is recommended that therapists not be restricted to a single theoretical approach. There is wisdom is learning some treatments that may not be preferred in addition to one’s preferred theory, particularly if there are master therapists available. Although workshops, video materials, and other resources are extremely valuable, it is wise to learn as much about particular theories as one can from local master therapists, supervisors, and clinical instructors, regardless of whether the theories espoused by these trainers are perfect matches for the trainee.
The fourth consideration when choosing a theory is related to eclecticism and theory integration (Arkowitz, 1992; Garfield, 1992; Norcross & Goldfried, 2005; Orlinsky & Rønnestad, 2005). It is quite rare that therapists choose only one theory because, as just stated, no one theory successfully and entirely explains human nature and behavior, and mental health or mental disorder. Therapists may well find that their visceral response to the theories presented encompasses two, three, or more different theories. Indeed, about a quarter of practicing psychologists have indicated that their approach is eclectic or integrationist (Norcross & Rogan, 2013). The key to adopting an eclectic theoretical framework is that the treatment delivered is a coherent, integrated, and strategic approach to healing. For example, a therapist may hold that humans are inherently good and, given the right circumstances, will flourish; that suffering is an integral part of existence; that knowledge is best gained through a deep understanding of others’ subjective reality; that systems, such as families, societies, and cultures, shape our personalities; that humans, although ultimately alone, live in relation to others; that humans are biological and instinctual beings and learn throughout our lifetime, and that affect cognition and behavior are intertwined. Given this example, obviously it is impossible to choose one theory that encapsulates all of these belief systems. It is possible to conceptualize a case psychodynamically and intervene cognitively, as long as the treatment makes sense to the client, is accepted by the client, and leads to client progress.
So far, the discussion has focused on the role of the therapist in selecting a theory. However, the theory also is important to the client, albeit in a different way. Typically, clients come to psychotherapy when their own efforts have been inadequate to overcome their difficulties and they believe that, despite their best efforts, their distress will continue. That is, their explanation for their disorders provides little hope for change. Clients may attribute their difficulties to internal factors over which they have no control (e.g., they are unintelligent) or external factors arrayed against them (e.g., people have treated them poorly and will do so in the future). A potent aspect of psychotherapy is that it provides an adaptive explanation—one that gives clients the expectation that their selves are not immutable and their problems are not inevitable (Frank & Frank, 1991; Wampold, 2007; Wampold & Imel, 2015). Of course, each theory tells the story differently—irrational thoughts, unconscious motivations, unexpressed emotions, poor attachment histories—but each tells a hopeful story to the client: If you believe in this new explanation and follow the steps in this treatment, your problems will be manageable and life will be better. In common factor models, acquisition of adaptive explanations is central to change in psychotherapy (Anderson, Lunnen, & Ogles, 2010; Frank & Frank, 1991; Imel & Wampold, 2008; Wampold, Imel, et al., 2006; Yulish et al., 2017).
Humans strive for understanding, and all healing practices provide an explanation in the language of the practice (e.g., medical explanations are biochemical). Yalom (1995) succinctly summarized the importance of explanation:
The unexplained—especially the fearful unexplained—cannot be tolerated for long. All cultures, through either a scientific or a religious explanation, attempt to make sense of chaotic and threatening situations. . . . One of our chief methods of control is through language. Giving a name to chaotic, unruly forces provides us with a sense of mastery or control. (p. 84)
Explanation itself is insufficient, however. The actions of specific therapies also are essential because they assist in the induction of belief in the explanation and promote an important set of healthy actions (Wampold, 2007; Yulish et al., 2017). Believing in an adaptive explanation and enacting healthy actions in therapy have been characterized in different ways by different theorists using different, but related, constructs, such as remoralization, mastery, self-efficacy, and change in response expectancies (Wampold, 2007; Wampold & Imel, 2015). Overall, the explanation provided by the therapist and acquired by the client is central to the process of psychotherapy (Yulish et al., 2017). This explanation is derived from the psychotherapy theory, again illustrating the essential role of psychotherapy theory.
There are several vital aspects of role of theory for the client. The issue of “truthiness” must be addressed here, as well. As is the case for the therapist, the scientific validity of theory is subsidiary to its utility for the client. If the explanation is cogent, is acceptable, creates positive expectations, and leads to healthy action, then it likely will be beneficial to the client. Indeed, the exact nature of the explanation, as understood by the therapist, is not what is communicated to the client. Just as medical doctors do not provide detailed biochemical explanations to their patients, therapists do not provide detailed psychological explanations. Rather, therapists provide explanations that are understandable and persuasive. Indeed, the explanation does not necessarily even have to be consistent with the theory the therapist is using, although usually it is. Again, therapists should be less concerned with the scientific validity of theory than they are with the impact of the explanation on the client, a point fully recognized by Donald Meichenbaum (1986), a prominent cognitive–behavioral therapist and scientist:
As part of the therapy rationale, the therapist conceptualized each client’s anxiety in terms of Schacter’s model of emotional arousal (Schacter, 1996). . . . After laying this groundwork, the therapist noted that the patient’s fear seemed to fit Schacter’s theory that an emotional state such as fear is in large part determined by the thoughts in which the client engages when physically aroused. . . . Although the theory and research upon which it is based have been criticized . . . , the theory has an aura of plausibility that the clients tend to accept: The logic of the treatment plan is clear to clients in light of this conceptualization. (p. 370)
An interesting coda to this discussion is that therapists, when seeking their own personal therapy, often do not select therapists of the same orientation as their own (Bike, Norcross, & Schatz, 2009; Norcross, Bike, & Evans, 2009), demonstrating a willingness to be theoretically flexible and not fastidiously invested in one true theory.
A critical aspect of the change process is the acceptance of the explanation provided by the therapist. The explanation should be compatible with the client’s attitudes and values. If not, the client is likely to resist the explanation. This consideration converges with the notion of culturally sensitive treatments that are discussed in the multicultural counseling literature (Atkinson, Bui, & Mori, 2001; Atkinson, Worthington, Dana, & Good, 1991; Benish, Quintana, & Wampold, 2011; Coleman & Wampold, 2003; Huey, Tilley, Jones, & Smith, 2014; Tao, Owen, Pace, & Imel, 2015). Certain types of clients are more prone to accept and benefit from certain types of treatments. For example, clients who are characteristically resistant benefit more from less structured treatments (Beutler, Harwood, Michelson, Song, & Holman, 2011), clients who are not ready to change respond poorly to therapists who impose action or premature change (Norcross et al., 2011), and clients do best when the internality/externality of the treatment match the internality/externality of their avoidance styles (Beutler, Harwood, Kimpara, Verdirame, & Blau, 2011).
Acceptance also is influenced by the person of the therapist. If the therapist is seen as a trusted healer, is persuasive, and works collaboratively with the client, it is more likely that the client will accept the offered explanation and be more engaged in the therapy (Wampold, 2007; Wampold & Imel, 2015). Effective therapists are quite persuasive when it comes to encouraging clients that a particular approach will be helpful (Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009; Goates-Jones & Hill, 2008). It appears that clients pick therapists based on personal characteristics, such reliability, warmth, empathy, and competence, rather than on a therapist’s theoretical orientation (Bike et al., 2009; Norcross et al., 2009; Wampold & Imel, 2015).
What seems to be clear is that if a client clearly is not attuned to the approach being offered and shows resistance to the treatment, persistently and insistently offering the same approach is not therapeutically helpful and probably is harmful (Henry, Schacht, Strupp, Butler, & Binder, 1993; Henry, Strupp, Butler, Schacht, & Binder, 1993). On the other hand, either not providing a cogent explanation to the client or providing a confusing explanation is not therapeutic, either (Yulish et al., 2017). Indeed, research has indicated that the purity of treatment is related to outcome (Luborsky, McLellan, Diguer, Woody, & Seligman, 1997; Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985), suggesting that, indeed, a coherent framework needs to be communicated to clients. This idea of purity of treatment should not be understood as slavish adherence to one theory and one theory only, however.
With regard to the client, it appears that a cogent, acceptable, and adaptive explanation must be present. Acceptance is based on the manner in which it is offered and on the characteristics and context of the clients. When it appears that the client is not accepting a treatment, either the treatment should be modified or another treatment should be used. This leads to the wise advice of Jerome Frank:
My position is not that technique is irrelevant to outcome. Rather, I maintain that . . . the success of all techniques depends on the patients’ sense of alliance with an actual or symbolic healer. This position implies that ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem. Also implied is that therapists should seek to learn as many approaches as they find congenial and convincing. Creating a good therapeutic match may involve both educating the patient about the therapist’s conceptual scheme and, if necessary, modifying the scheme to take into account the concepts the patient brings to therapy. (Frank & Frank, 1991, p. xv)
The discussion of the role of theory for the therapist and for the client has skirted the issue of how theory and science are related, a topic imbedded in the philosophy of science and one that many clinicians (and many researchers, for that matter) tend to avoid. The philosophical bases of theories are briefly discussed in Chapter 2, but the importance of the philosophy of science considerations is illustrated by examining Table 3.1.
At the dawn of the Enlightenment, there was a rejection of the meta-physical and a focus on observable relations. Emblematic of this change is the realization that Isaac Newton spent the early part of his life obsessed with the occult, filling notebooks with such machinations (Gleick, 2003) before turning his keen mind to observing nature. Auguste Comte is given credit for systematizing a philosophy of truth based on observation, known as positivism. Positivism, often carelessly associated with any empirical approach, is actually quite restricted and involves five principles (Hacking, 1983; Latour, 1999): (a) verification and the idea that disputes can be settled in some way (i.e., the notion of falsification by observation); (b) observation—that which can be sensed—is the foundation of knowledge (with the exception of mathematical knowledge); (c) causality is simply the regularity of antecedents and consequences (i.e., co-occurrence); (d) explanations are used to organize observations but have no deeper underlying role (i.e., there is no deeper structure to be discovered); and (e) as a consequence, theory, as commonly discussed, has no role. Positivists rejected metaphysical constructs but, by implication, also rejected the notion of theory more generally. An orthodox positivist would reject the notion of psychological constructs and causality, thereby disapproving of most theories of psychotherapy. Behavior therapy has its roots in positivism (Fishman & Franks, 1992), given that it has disallowed mentalistic constructs, focused on behavior (i.e., what can be observed), and sought functional relations, rather than causality. On philosophical grounds, behaviorism could be considered more “scientific” because it emanates from the positivistic tradition.
There is an interesting kink in the behaviorist adoption of positivism. If Treatment A, regardless of its nature, results in Outcome B, then its use and application is acceptable to behaviorists. So, if hypnosis results in a reduction in smoking, or eye movement desensitization and reprocessing reduces symptoms of posttraumatic stress disorder, these treatments are, to a radical behaviorist, behavior therapies. Behaviorists, of course, would reject the explanations provided by these theories because they involve mediating constructs that are not observable (Fishman & Franks, 1992), but the treatments themselves would be legitimate. Consequently, for the radical behaviorist, the introduction of cognitive components as theoretic constructs was problematic (Arnkoff & Glass, 1992; Fishman & Franks, 1992).
The positivist movement quickly was confronted with the thorny problems of language and meaning. The examination of language, meaning, and rational thought expanded positivism into what was known as logical positivism, which quickly left Comte’s quaint notions behind and focused on logic, meaning, and the analysis of language. Logical positivism retained an emphasis on empiricism but incorporated notions of deductive logic and emphasized the role of language in science (i.e., logic was expressed through language structures). The idea of verification of propositions emanated from logical positivism (Hacking, 1983). It is not unusual to use the term positivist in a pejorative way to denote an obsession with observation and a lack of theory, and thinking and eliminating the mind from any social science.
The next philosophical school that is important for our purposes is realism, which allows for entities that are unobservable. The constructs posited by a theory, if the theory is correct, are as real as entities that can be observed (Hacking, 1983). Accordingly, the unconscious is as real—if psychodynamic theory is valid—as are facial tics that one can observe. Indeed, modern psychoanalytic theorists point to much evidence that supports the notion of the unconscious (Weinberger & Westen, 2001; Westen, 1998). Most psychotherapy theories assume a quasirealist perspective and entertain unobservable constructs, but it should be realized that from a realist perspective, these actions depend on the validity of theory. It is interesting to note that most of heated debates about the origins of quantum theory have been about philosophy of science—positivists versus realists—and whether mathematical solutions are legitimate, even if they are devoid of observables or even of entities that could be visualized (e.g., dimensions beyond four; Jones, 2008).
That an entity is unobservable does not detract from its usefulness, as illustrated by Louis Pasteur’s discovery of germ theory:
In 1864, Louis Pasteur “discovered” that microorganisms were the cause of fermentation without ever observing the organisms; the microorganisms revealed themselves through the results of clever experiments, and that evidence was more persuasive than earlier attempts to establish a germ theory of disease (Latour, 1999). That the organisms were not objectively observed or that the window on reality was not transparent does not distract from the evidence that Pasteur produced, the empirical enterprise that formed the basis of his investigations, or the subsequent interventions that followed (e.g., vaccinations, pasteurization, and sterilization). Pasteur’s efforts were no more complex and no less controversial than investigations of the complexities of social interactions in many contexts, including, for example, Beebe, Knoblauch, Rustin, and Sorter’s (2005) effort to understand intersubjectivity in infant and adult interactions, including therapy. (Wampold, Goodheart, & Levant, 2007, p. 617)
A third school of philosophy that is germane to psychotherapy theory is phenomenology. Phenomenology, associated with the philosophers Søren Kierkegaard, Edmund Husserl, Martin Heidegger, and Jean-Paul Sartre, is concerned with issues related to the structure of experience and consciousness, particularly from the subjective first-person perspective. The focus is not on the objective qualities of things, events, or interactions, but on how they are perceived and interpreted by the individual. Phenomenology focuses on awareness of one’s own experience, self-awareness, linguistic activity (including how language reciprocally influences experience and meaning making), and relationship with others (e.g., empathy). As mentioned in the previous chapter, phenomenology gave rise to humanistic and existential approaches to therapy.
The final thread in these philosophies is what often is called constructivism or social constructivism, and sometimes are classified as postmodern philosophy (Hacking, 1999; Latour, 1999). The critique of positivism and realism is that they either eschew theoretical entities entirely or posit some underlying truth, which can be investigated by experiment. Constructivism posits that humans construct meaning and that there is no objective truth about anything social (Latour, 1999). This movement has some antecedents in logical positivism but goes further to claim that social phenomena are predominantly socially constructed realities. The predominant research approach in this area is qualitative research, such as grounded theory, which attempts to uncover the social constructions of the participants (Corbin & Strauss, 2015). As discussed in the previous chapter, multicultural counseling and psychotherapy, feminist therapy, and narrative therapy are closely allied to postmodern philosophy.
With this necessarily brief review, there are some important points to emphasize. In many ways, the schools of psychotherapy are derived from different philosophies of science: behavior therapy from positivism, psychoanalysis from realism (although Freud originally considered himself a positivist), humanistic and experiential from phenomenology, and multicultural and narrative therapy from social constructivism. Because the philosophies differ, the ground rules for deciding the relative worth of these approaches differ; more technically, the theories are incommensurable (Hacking, 1983). Even the research methods used to investigate the theories differ; for example, Schneider (2008) claimed that phenomenological methods (i.e., qualitative) are necessary to investigate existential psychotherapies, whereas behavioral theories focus on objective measures of symptoms. Incommensurability implies that no amount of debate or research evidence will result in a determination of the relative worth of the various approaches. Theories of psychotherapy are descriptive and useful, but their validity is indeterminable, in an important sense.
As discussed previously, one way of settling the relative worth or various approaches is to simply examine empirically their effects: Which treatments are more effective than others? Several issues render this strategy problematic. First, as is discussed in the next chapter, there are few differences among treatments in terms of outcomes, so empirically it makes little sense to persist in comparing treatments intended to be therapeutic. Second, the effort to compare two treatments without regard to theoretical considerations is a positivist pursuit that provides little in the way of understanding, even if differences could be found (Kazdin, 2009). Third, despite efforts, methods and theory are intertwined (Hacking, 1983). Comparative trials and ESTs are laden with behavioral and cognitive behavior aspects in terms of how outcomes are assessed (i.e., focus on symptoms) and how therapies are delivered (time limited and manualized). For example, experiential therapies are focused more on meaning and quality of life than on reduction of symptoms, and are more difficult to manualize (Schneider, 2008).
Psychotherapy theory is the road map that guides the therapist from point A to point B. Indeed, there can be no therapy without therapeutic actions, and the therapeutic actions emanate from theory. A cogent treatment is a fundamental element of psychotherapy. Choice of a theory involves multiple considerations on the part of the therapist and the client. To be effective, therapists need to have an allegiance to a theory; that is, they must believe that the application of the theory will result in benefits to the client. On the other hand, the client must believe in the explanation provided by the therapist. What is quite obvious to most observers is that master therapists practice widely divergent types of therapy and often operate from an integration of theoretical orientations, using interventions that are suitable and acceptable to the client. These therapists, although self-reflective, are passionate about the therapy approach they deliver.
Often therapists have an allegiance to a theoretical perspective without fully understanding the assumptions that come with the theory. The philosophy of science considerations renders the theories incommensurable; that is, there is no means to declare one theory superior to another. However, theory is absolutely necessary to guide practice.
Of course, there are limits on theories. Wampold (2007) discussed that individuals presenting to a healer expect an explanation and treatment that are consistent with the system of healing. Clients in a medical context expect a biological explanation for their symptoms and a treatment consistent with that explanation. Accordingly, clients who present to a psychologist expect a psychological explanation, which then limits therapists to legitimate psychological approaches. Many “crazy” psychotherapies have been proposed over the years (Singer & Lalich, 1996), and although some practitioners might use them successfully, psychologists should provide a treatment that falls within what is considered the psychological field. Of course, the boundaries of legitimate and “crazy” are fuzzy, but there are a sufficient number of legitimate therapies from which to choose.